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This is a lecture by Dr. Joseph Hartmann from the Ghana Emergency Medicine Collaborative. To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
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Project: Ghana Emergency Medicine Collaborative Document Title: Overuse Syndrome Author(s): Joseph H. Hartmann, DO License: Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/
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Overuse Syndrome
Joseph H. Hartmann, DO
A rose is a rose…
• Overuse syndrome • Repetitive stress disorder / injury • Repetitive motion disorder / injury • Repetitive strain disorder / injury • Cumulative trauma disorder • Musculoskeletal disorder
What is it?
• Repetitive activity over a variable course of time resulting in damage to tissue, usually muscular or ligamentous / tendinous (nerve entrapment also included).
• Repetitive activities – Occupational – Recreational (sport-related) – Habitual (Nintendo thumb, Nintendinits,
gamer’s thumb, PlayStation thumb)
Literary Digest, Wikimedia Commons
Unknown, Wikimedia Commons
Unknown, Wikimedia Commons
Bart, Flickr
Pathophysiology
• Tissue adaptation can not occur preventing healing
• Persistent trauma causes escalating injury – Mechanical effects – Biochemical effects
• Free radicals, prostaglandins, proinflammatory interleukins
– ? Genetic effects
Clinical Presentation - Hx
• Begin with PQRST questions • More specific detailing of suspected
offending activity – Repetitive activity (mechanism) – Technique employed
• Limbs malpositioned from neutral position
– Equipment used / worn
Clinical Presentation – P.E.
• Tenderness • Diminished ROM (active / passive) • Diminished strength • Tissue edema (?)
– Swelling of bursae, synovial sheaths • Evidence of musculoskeletal compensation • Classically recognized presentations
Laboratory Studies
• May or may not be indicated • General metabolic
– CBC, comprehensive medical panel with liver function testing, TSH
• Rheumatologic – ESR, CRP, ANA, RPR
Imaging Studies
• May or may not be indicated
– Acute on chronic injury – Significant worsening changes (unexplainable) – Mechanism of injury questioned
Radiographs
• Bony avulsions • Stress fractures • Chronic tendonitis
– Calcification of tendons • Myositis ossificans
• Bone scan / CT – Stress fractures
Source Undetermined
Source Undetermined
Source Undetermined
Ultrasound
• Ligament and tendon pathology – Opportunity for dynamic examination
• Higher resolution transducers provide higher spatial resolution rivaling MRI
• Procedural and professional costs are 20% that of comparable MRI study
Magnetic Resonance Imaging
• Historically more effective with acute injury than with more subtle findings associated with chronic injury
• Newer generation units, increasing experience, use of gandolinium enhance-ment with fat saturation (identifies inflamma-tion) has provided excellent soft-tissue resolution
Electrodiagnostic Studies
• EMG - NCT – Peripheral nerve compression / injury
• Location • Severity
• MRI ?
Treatment • Rest • Analgesics • Immobilization (?) • Physical therapy
– Supervised • To more carefully plan tx program • Use of modalities • Patient education
– Home exercise program
Treatment
• Occupational therapy – Tailor physical therapy – Identify workplace modifications
• Sports medicine therapy – Sport specific physical therapy – More knowledgably address
• Training issues • Technique flaws • Ill-fitting equipment
Treatment
• Steroid injections – Ligaments and tendons can undergo structural weakening leading to potential rupture
• Surgery – Failed conservative management
• Nerve decompression • Ligament repair (laxity)
– Dismal outcomes if performed for subjective pain relief without objective findings
Shoulder
• Impingement syndrome – Compression of supraspinatus tendon and
subacromial bursa – Pain with abduction (Neer maneuver) and
flexion / internal rotation (Hawkins maneuver) – Subacromial tenderness – Normal ROM – Normal strength
National Institute Of Arthritis And Musculoskeletal And Skin Diseases, Wikimedia Commons
Elbow • Epicondylitis
– Lateral epicondylitis • Extensor carpi radialis brevis and longus • “tennis elbow”
– Medial epicondylitis • Flexor carpi radialis • “golfer’s elbow”
– Pain with strong gripping – Decreased grip strength – Normal ROM
Gray’s Anatomy, Wikimedia Commons
Wrist and Hand
• Carpal tunnel syndrome – Median nerve entrapment – Symptoms typically worse at night – Typical sensory distribution – Flattening of thenar eminence – Thumb adduction weakness – Hoffman-Tinel test – tapping – Phalen maneuver - flexion
Gray’s Anatomy, Wikimedia Commons
Wrist and Hand
• deQuervain’s tenosynovitis – Involves abductor pollicus longus and brevis – Repetitive gripping / grasping motions – Local tenderness over radial styloid region – Pain with resisted thumb extension/abduction – Pain with passive ulnar deviation with thumb
adducted in palm – Finkelstein maneuver
PhilippN, Wikimedia Commons
Gray’s Anatomy, Wikimedia Commons
Hip
• Snapping hip syndrome – Usually from “iliotibial band snap”
• Snapping of thick,wide iliotibial tendon over greater trochanter with hip extension
– Snapping sensation – Audible “pop” – Commonly seen in runners – May cause a trochanter bursitis
Beth Ohara, Wikimedia Commons
Gray’s Anatomy, Wikimedia Commons
Knee
• Patellofemoral pain syndrome (chondromalacia patella) – “runner’s
knee” – Pain posterior to patella / anterior knee – Pain with compression of patella or with resisted
knee extension – Repetitive irritation – increased lateral forces on
patella – More commonly seen in women (anatomy)
Kari Stammen, Wikimedia Commons
Medial Tibial Stress Syndrome
• “shin splints” • Posteromedial margin of tibia • Dull aching discomfort relieved by rest • Progresses to worsening discomfort not
relieved by rest • ? Hyposthesia over fourth toe • r/o stress fx – “female athlete triad”
en:Anatomography, Wikimedia Commons
Gray’s Anatomy, Wikimedia Commons
Chronic Compartment Syndrome • Masquerades as other pain syndromes • Aching pain or cramping within 10-30 min in region of particular compartment • Exaggeration of normal exercise response
– Increased blood flow = increased muscle volume = decreased blood flow = compartment pressures above 20 mmHg
• Return to normal function between episodes • Non-urgent fasciotomy (?)
Sarte, Wikimedia Commons
Ankle / Foot
• Achilles tendonitis – Heel pain – Worse with dorsi-flexion – Retrocalcaneal bursa involvement
• Swelling, erythema, warmth
Gray’s Anatomy, Wikimedia Commons
Posterior Tibial Tendonitis
• Pain over medial ankle – Worse with inversion – Inability to stand on toes – Tenderness over tendon sheath – Often pronated flat foot found = overly-inverted
• Tarsal Tunnel Syndrome – Nerve entrapment of posterior tibial nerve
Plantar Fasciitis
• Involves plantar aponeurosis • Plantar heel and / or mid-foot pain • Passively dorsi-flex toes and palpate sole • Bilateral presentation 1/3 of patients
Wikimedia Commons
Lucien Monfils, Wikimedia Commons
Davius, Wikimedia Commons
Finally • Lengthy recovery times
– 4 – 6 weeks common – 6 months possible
• Return to pre-injury activities – Complete resolution on pain – Full range of motion – At least 90% recovered strength
• Prevention – Education – Modification